RFI Browser

Back  RFI # 1915: 271 multiple benefit plans

Formal vs. Informal Help Informal Formal

Submitter

Eric Scott

Description

We have some dental plans with a rider for Pediatric Dental Essential Health Benefits. How can I accurately codify the benefits for both the EHB rider and the standard benefits. Is this an allowed use of a message segment?

Example:
EB*A**23*****0****Y~
MSG*Essential Health Benefit~
EB*A**23*****.1****Y~
MSG*Standard Benefit~

Also, how can I indicate the order of payment. Procedures covered by the Essential Health Benefit will be paid at that level. Procedures not covered by the EHB will be paid at the standard benefit level.

Submitter Assigned Keywords

271 tiered benefit plan

Response

The ASC X12 271 transaction has the ability to handle multiple benefit plans with the multiple cost share options. The use of EB02 = CHD and the use of EB05 to indicate "Pediatric Dental Essential Health Benefits" along with the appropriate EB01 and EB03 codes would allow the separation of the pediatric benefit from the normal dental benefit. No MSG segment is needed in this instance.
Submission 3/26/2014
Status Date 4/28/2014
Status F - Final
Primary References
Document 005010X279A1
Section1.4.12
Set ID271
Loop2110C